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General Surgery
Cancer of the Esophagus
Built from Maingot's Abdominal Operations
What’s inside
13 sections · 185 slides
Overview
- Topics covered
Background and Causes
Where the disease occurs, who it strikes, and the exposures behind it
- Cancer of the esophagus in outline
- Early descriptions and the first resections
- From resection to reconstruction
- Global burden of esophageal cancer
- The Asian esophageal cancer belt
- High-incidence areas within China
- The shift from squamous cell cancer to adenocarcinoma
- Etiologic factors and the two cell types
- Smoking and alcohol
- Genetic predisposition in squamous cell cancer
- Aldehyde dehydrogenase 2 and the flushing response
- Acetaldehyde handling after a drink
- Which genotype carries the risk
- Diet and environment in squamous cell cancer
- Micronutrient deficiency and changing diet
- Field cancerization and second cancers
- Diseases that predispose to esophageal cancer
- Why adenocarcinoma is rising in the West
Screening, Surveillance and Prevention
Finding cancer before it causes symptoms, and trying to stop it forming
- Abrasive cytology in high-incidence areas
- Lugol's iodine chromoendoscopy of an early squamous cancer
- Narrow band imaging of the same lesion
- Chromoendoscopy with Lugol's iodine
- The Linxian nutritional intervention trial
- Arguments against screening the population for Barrett's esophagus
- Surveillance once Barrett's esophagus is found
- Dysplasia grade and surveillance interval
- The metaplasia-dysplasia-cancer sequence
- Chemoprevention in Barrett's esophagus
Clinical Presentation
What patients complain of, and how the two cell types differ at the bedside
- Symptoms of advanced esophageal cancer
- Odynophagia, hoarseness and the clues they give
- Two different patients behind the two cell types
- Squamous cell cancer and adenocarcinoma compared
Tumour Staging
How deep, how many nodes, how far - and how the categories are grouped
- Purpose of accurate staging
- T categories for the primary tumour
- Depth of invasion behind the T categories
- Reading the T categories
- N and M categories
- Counting nodes for the N category
- What changed in the revised TNM system
- Histologic grade categories
- Grade of differentiation
- Stage groupings for squamous cell carcinoma
- Stage groupings for adenocarcinoma
- Why the two cell types are grouped differently
- Levels of the esophagus used in staging
- Levels of the esophagus
- Lymph node stations of the esophagus
- American Joint Committee on Cancer node stations
- Staging tumours at the gastroesophageal junction
- Siewert classification of junctional adenocarcinoma
- Type I adenocarcinoma arising from Barrett's esophagus
- Type II cardia cancer specimen and barium study
- Siewert types I, II and III
- Divisions of T1 tumours by the Japan Esophageal Society
- Subdividing T1a and T1b
Methods of Staging
The investigations that answer depth, nodes and distant spread
- What each staging test answers best
- Barium contrast studies
- Barium study of a stenotic tumour
- Bronchoscopy
- Computed tomography for distant disease
- Computed tomography for local and nodal disease
- Combined PET and CT of a hilar node
- Endoscopic ultrasound and the wall layers
- Endoscopic ultrasound of an early mucosal tumour
- Accuracy and reach of endoscopic ultrasound
- The non-traversable stricture
- Percutaneous ultrasound of neck nodes
- FDG-PET for the primary tumour
- FDG-PET for regional nodes
- Does PET change the operative decision
- Thoracoscopic and laparoscopic staging
Treatment of Early Cancer
Removing the disease through the endoscope, and when that is not enough
- Depth and nodal risk in early squamous cell cancer
- 0%
- Selecting lesions for endoscopic resection
- Indications for endoscopic resection of esophageal cancer
- Cap-assisted endoscopic mucosal resection
- Results of endoscopic mucosal resection
- Endoscopic submucosal dissection
- Complications of endoscopic resection
- The case against watching high-grade dysplasia
- Invasive cancer hidden inside high-grade dysplasia
- Localized resection in Barrett's cancer
- Circumferential resection and whole-segment ablation
- Photodynamic therapy
- Radiofrequency ablation devices
- Radiofrequency ablation in non-dysplastic Barrett's esophagus
- Randomized trial of ablation for dysplastic Barrett's esophagus
- Vagal-sparing and limited resection
- Choosing between the three options
Surgical Resection for Advanced Cancer
Choosing the patient, the approach, the margins and the node clearance
- Patient selection for esophagectomy
- Predictors of morbidity and mortality
- Risk scoring before esophagectomy
- Pharyngolaryngoesophagectomy for cervical cancer
- Reconstruction after cervical resection
- Sacrificing the larynx, and the alternative
- Three-phase (McKeown) esophagectomy
- Phases of the Lewis-Tanner operation
- The Lewis-Tanner operation
- The left thoracotomy approach
- The transhiatal approach
- Abdominal esophagus and cardia tumours
- Transthoracic and transhiatal resection compared
- The argument over access
- The randomized trial of transhiatal versus transthoracic resection
- Choosing an approach by tumour site
- Minimally invasive esophagectomy
- Evidence for minimally invasive esophagectomy
- Why the benefit is hard to prove
- R0 resection and the axial margin
- How long a proximal margin
- Limits of margin status
- Lateral margin and en bloc resection
- Extent of lymphadenectomy
- Standard, extended and three-field clearance
- Standard and extended mediastinal lymphadenectomy
- Total mediastinal lymphadenectomy
- Nodal spread in squamous cell cancer
- Infracarinal mediastinal dissection
- Superior mediastinal dissection
- Right recurrent laryngeal nerve node dissection
- Abdominal lymphadenectomy at the celiac trifurcation
- Cervical lymphadenectomy
- Morbidity of three-field lymphadenectomy
- Refining the indications
- Criticism of three-field dissection
- Nodal spread in Barrett's adenocarcinoma
- En bloc resection results
- Surgery for cardia cancer
- The JCOG 9502 trial
- Number of nodes removed and survival
- ~10
Reconstruction After Esophagectomy
Which organ replaces the esophagus, by which route, and how it functions
- The gastric conduit
- Gastric conduit prepared for transposition to the neck
- Drawbacks of the gastric conduit
- Gastric emptying after esophagectomy
- Colonic interposition
- Jejunal reconstruction
- Route of the conduit
- Recurrent tumour and the reconstruction route
Perioperative Care and Complications
The complications that determine whether the operation succeeds
- Cardiac events and atrial arrhythmia
- Pulmonary complications
- Reducing pulmonary complications
- Anastomotic leak
- Stapled versus hand-sewn anastomosis
- Technical complications drive outcome
- Improvement in leak outcomes over time
Multimodal Treatment
Radiotherapy, chemotherapy and chemoradiation around the operation
- Neoadjuvant radiotherapy
- Adjuvant radiotherapy
- Randomized trials of neoadjuvant chemotherapy versus surgery
- The Intergroup INT 0113 trial
- The MRC OE02 trial
- JCOG 9907 and the MAGIC trial
- Meta-analyses of preoperative chemotherapy
- Adjuvant chemotherapy
- Randomized trials of neoadjuvant chemoradiation, first group
- Randomized trials of neoadjuvant chemoradiation, remaining trials
- Neoadjuvant chemoradiation trials
- Meta-analysis of neoadjuvant chemoradiation
- Definitive chemoradiation without surgery
- The FFCD 9102 trial
- The German chemoradiation trial
- Why it is premature to abandon surgery
- Local control and residual disease
- Predicting response to treatment
- PET/CT before and after chemoradiation therapy
- The MUNICON trial
- Results of the MUNICON trial
- The MUNICON-2 trial
- Newer drugs and radiation techniques
Endoscopic Palliation
Restoring swallowing when cure is no longer possible
- Self-expanding metallic stents
- Self-expanding metallic stent in situ
- Metallic versus plastic prostheses
- Problems with metallic stents
- Restoring patency and choosing a stent
- Stents near the upper esophageal sphincter
Summary and Future Directions
Where treatment stands, and what still has to be solved
- Where treatment stands
- Remaining problems
- Points to carry away
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition